When people in the rural areas of Maine have a bad toothache, they might turn to a medical clinician for help—instead of a dentist.
That’s because Maine has one dentist for every 2,300 people, compared with a national ratio of 1:1,600, according to the New York Times. This shortage exists, in part, because not one dental school exists in the state of Maine. The closest dental training program is in Boston. Those dentists who do practice in the state are not well distributed; most are centered around the large city of Portland.
So, in 2005, the Maine Dental Association teamed up with the Maine Dartmouth Family Practice Residency program in Augusta to begin teaching medical residents to know their way around the mouth. Several PAs and NPs also participated in the program, according to Richard Schmidt, DDS, a member of the Maine Dental Association, who does much of the dental training.
Schmidt says he would welcome more contact from other NP and PA schools, since rural clinics tend to be staffed primarily by these clinicians. “They are the first line of defense,” Schmidt says. “They’re the first to see these patients, and it’s critically important that they have the same understanding as the primary care doctors. The more they know, the better off we all are.”
Numbing the Pain
Medical providers often know very little about oral health (other than checking for enlarged tonsils or a sore throat), says Francis Miliano, Executive Director of the Maine Dental Association. Since many diseases manifest first in the mouth, it’s an important knowledge gap to fill.
Of course, the goal is not to have the medical residents replace an actual dentist. “It’s really only for emergency situations,” Miliano says. “Dr. Schmidt teaches them to recognize what they can do themselves without getting into trouble—and when to refer to a dentist.”
Approximately 20,000 low-income Maine residents have no dental insurance, Schmidt says, so they often postpone preventive dental care. When a problem arises, they usually end up in the emergency department (ED), in a great deal of pain.
When faced with patients in a dental crisis, medical providers who have been through Schmidt’s program are armed with some basic tools. They know how to provide local anesthesia, extract teeth, and prescribe antibiotics to prevent infection. They also have a list of dentists on hand if they need to refer the patient for more in-depth follow-up care.
“In medical school, they get zero exposure to the oral cavity,” Schmidt says. “They don’t look at the tongue, lips, mucosa, or teeth, because they are not trained to do that.”
Drilling Down to the Needs
Out west, Peter Jensen, DDS, is making similar inroads in rural New Mexico, where there also is a shortage of dentists. Jensen is Director of the Advanced and General Dentistry Residency Program at the University of New Mexico School of Medicine in Albuquerque.
Like Schmidt in Maine, Jensen is working closely with University of New Mexico medical residents. He has been offering dental training to them since 2004. Typically, it’s the ED doctors or residents specializing in otorhinolaryngology who choose elective rotations in the dental program, Jensen says.
“After they finish residency, they will come and get additional training in operating room dentistry, subspecialty areas, or general dentistry,” Jensen says. “We’ve taught them how to extract teeth and give anesthetic blocks in the mouth.”
As a next step, Jensen would like to work with more NP and PA training programs within the state and from around the country. Like Schmidt, he recognizes how important these clinicians are as the first caregivers patients often see in rural America.
Extracting Value
Maine Dental Association’s Schmidt sometimes worries that his training efforts are “a drop in the bucket,” but he still believes it’s worth it. He feels better knowing those residents and clinicians are out there, armed with information and ready to help in an emergency. “When they go out into the real world,” he says, “I want them to understand what they’re looking at in the mouth.”
Suggested Reading
Danielsen R, Dillenberg J, Bay C. Oral health competencies for physician assistants and nurse practitioners. J Physician Assistant Education. 2006; 17(4):12-16.
Rizzolo D, Sedrak MM. Oral pathology. Clinician Reviews. 2009;19(6):26-30.
Wendel OT, Glick M. Your role in oral health care. Clinician Reviews. 2008;18(11):Cover, 32.